MEDICARE BILLING: FORM CMS15-00 AND THE 837 ...

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MEDICARE BILLING: FORM CMS-1500 AND THE

837 PROFESSIONAL

TARGET AUDIENCE: Medicare Fee-For-Service Providers

The Hyperlink Table at the end of the document provides the complete URL for each hyperlink.

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Medicare Billing: Form CMS-1500 and the 837 Professional

CONTENTS

WHAT ARE THE 837P AND FORM CMS-1500? 837P Form CMS-1500

ANSI ASC X12N 837P IMPLEMENTATION AND COMPANION GUIDES FOR ELECTRONIC TRANSACTIONS MEDICARE CLAIMS SUBMISSIONS CODING

Diagnosis Coding Procedure Coding SUBMITTING ACCURATE CLAIMS WHEN DOES MEDICARE ACCEPT A FORM CMS-1500? ASCA Exceptions Waiver Requests TIMELY FILING WHERE TO SUBMIT FFS CLAIMS RESOURCES HYPERLINKS

MLN Booklet

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4 4 4 5 5 5 6 6 6 7 7 8 10

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Medicare Billing: Form CMS-1500 and the 837 Professional

MLN Booklet

WHAT ARE THE 837P AND FORM CMS-1500?

837P The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. Review the chart below ANSI ASC X12N 837P for more information about this claim format.

Form CMS-1500 The Form CMS-1500 is the standard paper claim form health care professionals and suppliers use to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. Centers for Medicare & Medicaid Services (CMS) designates the 1500 Health Insurance Claim Form as the CMS-1500 (02/12) and the form is referred to throughout this fact sheet as the CMS-1500.

In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers. Data elements in the CMS uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both.

ANSI ASC X12N 837P

The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional) Version 5010A1 is the current electronic claim version.

To learn more, visit the ASC X12 website.

ANSI = American National Standards Institute ASC = Accredited Standards Committee X12N = Insurance section of ASC X12 for the health insurance industry's administrative transactions 837 = Standard format for transmitting health care claims electronically P = Professional version of the 837 electronic format Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers.

The National Uniform Claim Committee (NUCC) developed a crosswalk between the ASC X12N 837P and the hard copy claim form. MACs may also include a crosswalk on their websites.

CPT Disclaimer-American Medical Association (AMA) Notice CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All rights reserved. Applicable FARS/HHSAR apply. CPT only copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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IMPLEMENTATION AND COMPANION GUIDES FOR ELECTRONIC TRANSACTIONS

Health care professionals or suppliers billing electronic claims must comply with the ASC X12N implementation guide. The 837P Health Care Claim: Professional Implementation Guide is available for purchase and provides instructions on the content and format requirements for each of the standards' requirements. ASC X12N implementation guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards' requirements. These documents are written for all health benefit payers, not specifically for Medicare. You can purchase Implementation Guides, including Version 5010 Consolidated Guides from the Washington Publishing Company.

CMS publishes a companion guide to supplement the implementation guide and to provide further instruction specific to Medicare. The 5010A1 Part B 837 Companion Guide provides specific 837P claim loop and segment references.

Please note, the implementation guides and companion guides are technical documents and health care professionals or suppliers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

MEDICARE CLAIMS SUBMISSIONS

The Medicare Claims Processing Manual (Internet-Only Manual [IOM] Pub. 100-04) includes instructions on claim submission. Chapter 1 includes general billing requirements for various health care professionals and suppliers. Other chapters offer claims submission information specific to a health care professional or supplier type. Once in IOM Pub. 100-04, look for a chapter(s) applicable to your health care professional or supplier type and then search within the chapter for claims submission guidelines. For example, Chapter 20 is entitled Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

Visit Chapter 24 to learn more about electronic filing requirements, including the Electronic Data Interchange (EDI) enrollment form that must be completed prior to submitting Electronic Claims or other EDI transactions to Medicare. Refer to Chapter 26 to learn what should be included in each field of the CMS-1500. The Medicare Benefit Policy Manual (IOM Pub. 100-02) and the Medicare National Coverage Determinations (NCD) Manual (IOM Pub. 100-03) both include coverage information that may be helpful in claims submission. Search for coverage guidance once within a chapter.

CODING

Correct coding is key when submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code the claims to the highest level of specificity (maximum number of digits available). Chapter 23 of the Medicare Claims Processing Manual is entitled Fee Schedule Administration and Coding Requirements and includes information on diagnosis coding and procedure coding, as well as instructions for codes with modifiers.

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Diagnosis Coding The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), is currently used to code diagnostic information on claims. Visit the Centers for Disease Control and Prevention website to access ICD-10-CM codes electronically or you may purchase hard copy code books from code book publishers.

Procedure Coding Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to code procedures on all claims. Level I Current Procedural Terminology (CPT-4) codes describe medical procedures and professional services. CPT is a numeric coding system maintained by the American Medical Association (AMA). Visit the AMA Bookstore to purchase the CPT code book.

The Medicare Learning Network? (MLN) has an Evaluation and Management (E/M) codes guide. These codes are a subset of HCPCS Level I codes.

Level II of the HCPCS is a standardized coding system used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and DMEPOS, when used outside a physician's office or injections administered within a physician's office or clinic. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the Level II HCPCS codes, or alpha-numeric codes as they may be referred to, were established for submitting claims for these items. To view these codes, you may review the HCPCS code book or visit the Alpha-Numeric HCPCS webpage.

SUBMITTING ACCURATE CLAIMS

Health care professionals and suppliers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.

Modifiers Proper use of modifiers with procedure codes is essential to submitting correct claims. The AMA's CPT code book includes HCPCS Level I codes and modifiers, while the HCPCS code book includes HCPCS Level II codes and related modifiers. Resources about modifiers on the CMS website include:

? The Modifier 59 article which explains the correct use of -59 as a distinct procedural service.

? The Physician Bonuses webpage which outlines whether or not a modifier is required to receive the Health Professional Shortage Area (HPSA) bonus payment.

? Chapters of the Medicare Claims Processing Manual (IOM Pub. 100-04) which also offer modifier information. For example, Chapter 30 includes information related to modifiers for Advance Beneficiary

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